LASGB
is a simple and safe procedure, but some reports have suggested
disappointing long-term results. Despite the recent widespread use of
LASGB, there are no prospective nor randomized trials comparing LASGB
with other laparoscopic procedures.

Methods:

A total of 100 morbidly obese patients, with body mass index (BMI) 40 to 50 kg/m2,
without compulsive eating, were randomized to either LASGB (n = 49) or
LVBG (n = 51). Minimum follow-up was 2 years (mean 33.1 months).

Results:

There were no deaths or conversions in either group. Mean operative time was 94.2 minutes in LVBGs and 65.4 in LASGBs (P < 0.05). Early morbidity rate was lower in LASGBs (6.1%) versus LVBGs (9.8%) (P = 0.754). Mean hospital stay was shorter in LASGBs versus LVBGs: 3.7 days versus 6.6 (P < 0.05). Late complications rate in LVBGs was 14% (7 of 50) and in LASGBs 32.7% (16 of 49) (P
< 0.05). The most frequent complication was the slippage of the band
(18%). Late reoperations rate in LVBGs was 0% (0 of 50) versus 24.5%
(12 of 49) in LASGBs (P < 0.001). Excess weight loss in
LVBGs was, at 2 years, 63.5% and, at 3 years, 58.9%; in LASGBs, excess
weight loss, respectively, was 41.4% and 39%. BMI in LVBGs was, at 2
years, 29.7 kg/m2 and, at 3 years, 30.7 kg/m2; in LASGBs, BMI was 34.8 kg/m2 at 2 years and 35.7 kg/m2
at 3 years. According to Reinhold’s classification, a residual excess
weight <50% was achieved, at 2 years, in 74% of LVBG and 35% of
LASGB (P < 0.001).

Conclusions:

This study demonstrates that, in patients with BMI 40 to 50 kg/m2,
LASGB requires shorter operative time and hospital stay but LVBG is
more effective in terms of late complications, reoperations, and weight
loss.

The
introduction of laparoscopic surgery has created a revolution in the
field of bariatric surgery. Laparoscopic procedures have progressively
replaced traditional open bariatric procedures in both Europe and North
America. Although gastric bypass1–3 and duodenal switch4 currently represent 80% of laparoscopic bariatric procedures in the United States and Canada,5 in Europe laparoscopic gastric restrictive procedures still represent the majority of bariatric procedures.6,7
Two reasons explain this disparity. First, different diet habits lead
to a better response in European patients following gastric restrictive
procedures. Second, most European patients present for bariatric
surgery with a body mass index (BMI) between 35 and 50 kg/m2, and superobese patients (BMI >50 kg/m2) remain a rare entity. Gastric restrictive procedures frequently fail in the superobese patient population.8,9

Laparoscopic
adjustable silicone gastric banding (LASGB) was the first bariatric
procedure to be performed by a laparoscopic approach.10–12
Introduction of LASGB into clinical practice was an immediate success.
It caused the rapid growth of bariatric programs in surgical
departments throughout European countries, where these procedures were
limited to a few centers in the past. Despite the recent widespread use
of LASGB, long-term outcome evidence is limited.13

Moreover, few studies provide precise data for long-term follow-up.14–16 Some studies even report disappointing long-term results.17,18
To the best of our knowledge, there are no prospective studies or
randomized controlled trials comparing LASGB to other laparoscopic
bariatric procedures.

The randomized trial published by Nilsell et al,19
comparing adjustable gastric banding and vertical banded gastroplasty
(VBG), was related to open procedures. To date, randomized controlled
trials have addressed different technical variations of one
laparoscopic bariatric procedure,20 or they have compared the traditional open approach with a minimally invasive approach for the same procedure.21–23
To fully validate LASGB, we must gauge it against other restrictive
laparoscopic procedures. The aim of this study is to compare LASGB with
laparoscopic vertical banded gastroplasty (LVBG). LVBG was the most
popular gastric restrictive procedure during the prelaparoscopic era.
In our experience, LVBG continues to provide satisfactory outcomes when
performed with a minimally invasive approach.24 Therefore, it is appropriate for comparison with LASGB.

Patients
were evaluated by a dietician to exclude concentrated “sweet” eaters
and “binge” eaters. These two groups of patients represent a well-known
contraindication to restrictive bariatric procedures.25
Patients were considered eligible after evaluation of clinical history,
a thorough physical examination, blood chemistry, hormonal status,
esophagogastroduodenoscopy, barium meal, esophageal manometry, 24-hour
pH-metry, spirometry, and abdominal ultrasound (if cholelithiasis were
present, a cholecystectomy was routinely performed at the time of
bariatric surgery).

Multiple
preoperative interviews were conducted with the patients with the goal
of creating a clear understanding of expected benefits, risks, and
long-term consequences of gastric restrictive procedures. This included
establishing a clear representation of the anticipated postoperative
changes in eating habits, necessary behavior modifications, and
requisite prolonged follow-up with nutritional counseling and testing.
A special consent form signed by the patient was also required for
trial inclusion.

Surgical Techniques

LASGB

The
LapBand (Bioenterics, Carpinteria, CA) was used in all patients. The
patient was placed in a steep reverse Trendelenburg position. The
laparoscopic procedure was carried out through five operative ports
positioned in the upper abdomen, after insufflation was achieved in all
cases with a Veress needle inserted in the left hypochondrium. The
calibration tube (Bioenterics) was passed transorally by the
anesthetist into the stomach. Twenty-five milliliters of saline was
added to the balloon, and the tube was gently withdrawn from the mouth
until the balloon seated at the gastroesophageal junction.

Dissection
of the retrogastric tunnel commenced at a point on the lesser curve
level with the equator of the balloon. Dissection was performed with an
articulating dissector, close to the gastric wall, and carefully
maintained above the lesser sac. Once the left diaphragmatic crus was
reached, the LapBand was introduced through a 15-mm port and the end
plug placed in the dissector slot. While the balloon was inflated with
15 mL of saline, the band was positioned and locked to calibrate the
pouch. To keep the band in place, four seromuscular nonabsorbable
sutures were placed between the pouch and the anterior gastric wall
immediately below the band. The tubing was connected to the access port
positioned subcutaneously in the left upper abdomen, and the band was
left deflated at the end of the operation.

LVBG

The
patient was placed in a steep reverse Trendelenburg position. The
operation was performed through six ports. Laparoscopic dissection
started on the lesser curvature of the stomach at 6 cm from the
gastroesophageal junction. At this level, the lesser omentum was
progressively dissected close to the stomach wall to gain access to the
lesser sac. A 2-cm window was developed.

The
transgastric window was then created. A 12-mm diameter calibrating tube
was introduced into the stomach and grasped with an Endobabcock (Tyco
HealthCare, AutoSuture Company, United States Surgical Corporation,
Norwalk, CT) along the lesser gastric curve to serve as a guide for
calibration of the outlet. The 15-mm port in the right upper abdomen
was withdrawn and a 21-mm-diameter circular stapler (ECS 21, Ethicon
Endosurgery, Cincinnati, OH) was inserted percutaneously. The stapler
penetrated the lesser sac via the window along the lesser gastric
curve. Both gastric walls were perforated by the stapler prior to
mating with the anvil and firing of the stapler. An Endo-GIA stapler
(Tyco HealthCare) 60 mm in length, using 4.8-mm staples, was inserted
through the gastric window and directed toward the angle of His. The
calibrating tube was kept in place along the lesser curve. Typically,
two stapler cartridges were necessary to complete the pouch.

All
staple lines were carefully inspected. Bleeding vessels were
suture-ligated with polypropylene sutures and extracorporeal knotting.
Finally, a polypropylene mesh band was premarked. It was wrapped flat
around the gastric pouch outlet and sutured to itself to create a 5-cm
circumference to calibrate the gastric pouch outlet.

Outcome Assessment

All
patients underwent an upper gastrointestinal evaluation with
hydrosoluble contrast medium on the first (LASGB) or on the second
(LVBG) postoperative day.

Follow-up
visits, clinical evaluations, and blood tests were scheduled every 3
months during the first year, annually thereafter. Twenty-four-hour
pH-metry and esophageal manometry were performed at 3 and 12 months
postoperatively. An upper gastrointestinal series with barium meal and
a gastroscopy were typically carried out at 1 and 3 years
postoperatively and in the case of clinical symptoms or nonsatisfying
weight loss. Unsatisfactory weight loss was defined as weight loss at 3
months <20% of excess body weight loss (EWL), at 6 months <30%
EWL, or at 1 year and after <40% EWL. In cases of unsatisfactory
weight loss following LASGB, a band recalibration was performed by
inflating the band with 1 to 1.5 mL saline under fluoroscopic control;
a clinical examination was scheduled 20 days after each band
recalibration.

The
following data were recorded: surgical time (time between skin incision
and closure of the wound), anaesthesiology time (global time in the
operative room), conversion rate, intraoperative and postoperative
morbidity, 60-day mortality, and length of hospital stay. Long-term
complications, additional procedures, readmissions, and hospital stay
were also evaluated. Percentage of EWL, Reinhold classification,26
and residual BMI were used to describe the postoperative results. Ideal
weight was determined by the use of Metropolitan Life Insurance Company
tables.27
The results were expressed as excellent when the patient had 0% to 25%
excess weight, a good result was 26% to 50%, a fair result was 51% to
75%, a poor result was 76% to 100%, and a failure was >100% excess
weight at the time of evaluation.

Statistical Analysis

The
primary endpoint of the study was reoperation rate. Secondary endpoints
were early and late complication rates, and percent EWL at 1, 2, and 3
years. Appropriate sample size was calculated based on assumption of a
difference of 5% in the reoperation rate between LASGB and LVBG, a
difference of 5% in early and late complications, and a difference of
10% in percent EWL. These differences were considered clinically
significant, and a sample size of 100 patients (50 in each group) was
needed to prove these differences. Randomization was performed 1 day
before surgery by means of sealed opaque envelopes containing
computer-generated random numbers. Categorical variables were compared
by χ2 test, with Yates correction and the Fisher exact test
(two-tailed) when necessary. Continuous variables were compared by the
Student t test or the Mann-Whitney U test, depending on distribution. All P values were two-sided. A P value of <0.05 indicated a statistically significant difference. All calculations were done with SPSS (version 10.0).

A total of 100
patients were randomized to either LASGB (n = 49) or LVBG (n = 51). The
two groups were comparable in sex, age, mean weight, BMI, percent EW,
and laboratory test results (Table 1).
An associated procedure was performed in 10% of both groups. Four
cholecystectomies and one lymph node biopsy were performed in Group A.
Five cholecystectomies were performed in Group B. There were no deaths
or conversions to open surgery in either group. The mean operative time
was significantly longer in the LVBG group versus LASGB: 94.2 minutes
(range 40–270 minutes) versus 65.4 minutes (range 35–120 minutes) (P
< 0.05). Early postoperative morbidity was less frequent in the
LASGB group (6.1%) versus LVBG (9.8%), but it did not reach statistical
significance (P = 0.754) (Table 2).
There was one early postoperative band slippage in LASGB, on
postoperative day 7. It was treated by laparoscopic repositioning.
Also, there was one port infection and one hematoma at the port site.

TABLE 1. Patient Demographic Data

TABLE 2. Operative Results and Complication Rate

In
the LVBG group, we experienced one fistula at the staple line diagnosed
at the second postoperative day and treated with open gastric bypass.
There were two cases of prolonged postoperative pyrexia that resolved
with nonoperative treatment. Two respiratory failures, without evidence
of pulmonary embolism, resolved with conservative therapy. Therefore,
one patient in each group underwent an early reoperation.

Mean
length of hospital stay was shorter in the LASGB group (3.7 days)
versus LVBG (6.6 days), which was statistically significant (P < 0.05) (Table 2).
All patients underwent a minimum follow-up of 2 years: mean 33.1 months
(range 24–46 months). Patients present at follow-up were: 98% at 1
year, 94% at 2 years, 90% at 3 years in the LASGB group and 90%, 88%,
and 95%, respectively, in the LVBG group.

Concerning
long-term complications and reoperations following these operations,
LVBG was superior to LASGB. Late complications in LVBG were seen in 14%
(7 of 50) of patients versus 32.7% (16 of 49) in LASGB patients. This
was statistically significant (P < 0.05). Late reoperations
in LVBG were not required (0 of 50) while 24.5% (12 of 49) of the LASGB
group required another operation. Again, this was statistically
significant (P < 0.001). In the LVBG group, complications
included one pouch dilatation, an asymptomatic pouch-to-fundus fistula,
four symptomatic reflux diseases, and a gastric bezoar. Again, no
reoperations were performed in the LVBG group.

In
the LASGB group, there were nine cases of gastric band slippage, three
patients with symptomatic reflux diseases, one patient suffered
complete food intolerance, one poor compliance, one port was infected,
and one port twisted. There were 12 reoperations performed in the LASGB
patients. Eight bands were removed (in six cases for slipping, in one
case for severe reflux esophagitis, in one case for poor compliance; in
two cases a LVBG was performed). One band slipped was laparoscopically
replaced, one patient underwent a gastric bypass because of food
intolerance without complications related to the band, one port was
repositioned, and one port was removed.

Finally, LVBG was significantly superior to LASGB in terms of weight loss as shown in Figure 1.
If we consider results according to Reinhold’s classification, an
excellent or good result (residual excess weight < 50%) was achieved
at 2 years in 35% of LASGB and in 74% of LVBG (P < 0.001); at 3 years in 25% of LASGB and in 63% of LVBG (P
= 0.056). Procedural failure resulting from insufficient weight loss
(residual excess weight >100%) was present in 5% and 6% at 2 and 3
years in the LASGB patients, while no failures were seen in the LVBG
group.

In
recent years, a minimally invasive approach has become the preferred
technique for bariatric surgery. Explanations for this trend include
several advantages related to less postoperative discomfort and reduced
surgical risk for obese patients. All bariatric procedures are now
routinely performed laparoscopically. Beginning with LASGB11–13 and LVBG,24,28,29 followed by gastric bypass,1,2,3,30 duodenal switch,31 and biliopancreatic diversion,32,33
the laparoscopic approach has gradually replaced the corresponding
traditional open operations. A limited number of prospective studies
and randomized trials have compared the open technique with the
minimally invasive approach for the same operation.21–23 There are no studies comparing different laparoscopic bariatric procedures.

In
Europe, the tumultuous development of LASGB was based on the simplicity
and feasibility of the technique with an excellent immediate
postoperative course.14–16.
However, there is limited availability of midterm and long-term
results. Moreover, no clinical comparisons have been reported in the
literature between an innovative procedure like LASGB and other
restrictive bariatric procedures.

Recently, some concern has arisen regarding the efficacy of restrictive gastric procedures as therapy for morbid obesity.25,34,35
For this reason, the majority of U.S. surgeons have leaned toward
malabsorptive procedures or mixed restrictive and malabsorptive
procedures. However, gastric restrictive surgery remains prominent in
Europe. Success of these procedures in Europe is probably due to the
different diet habits and to a lower mean BMI of European bariatric
patients addressed to surgery.

We
began the present study with purpose of comparing LASGB with the LVBG
involving a complete transection of the stomach. Vertical banded
gastroplasty was the bariatric restrictive procedure of choice at the
time, before the advent of laparoscopy.36 We were successful in obtaining excellent results with the laparoscopic approach24 and have subsequently focused on the comparison of these two laparoscopic procedures.

Following its introduction, the technique of LASGB underwent several modifications.37
Recently, different models of restrictive bands have been developed. At
the time of our study, two models of bands were available: the heavily
favored LapBand and the Swedish band (Obtech, St. Anton, Switzerland).
For this reason, we decided to use the LapBand in the present study. It
is noteworthy that the LapBand is the only model of gastric restrictive
band currently approved by the Food and Drug Administration for
clinical use.

Regarding LVBG, we used the technique previously described, transferring the Mason’s classic technique38 to the laparoscopic approach.24 We modified the procedure as described by McLean et al,36
with complete transection of the stomach. This avoids gastrogastric
fistulas along the longitudinal gastric staple line, which leads to
failure.

Our study demonstrated
the feasibility and reproducibility of both procedures with a
laparoscopy-to-open conversion rate of 0% in both groups. LASGB was
significantly shorter, with a mean operative time of 65 minutes versus
94 minutes for LVBG (P < 0.05). Both procedures were safe
without mortality. However, LASGB had inferior morbidity, although this
did not reach statistical significance (6.1% vs. 9.8%; P =
0.754). The need for early reoperation rate was the same in both
groups. Shorter operative time, lower morbidity, and a smoother
postoperative course led to shorter mean length of hospitalization in
the LASGB group (3.7 vs. 6.6 days with P < 0.05). These
comparatively lengthy mean hospital stays were due to Italian health
care system management. They were not related to problematic
postoperative episodes except for the patient who developed a
postoperative fistula after LVBG with a prolonged hospital stay of 120
days. Actually, these mean lengths of stay are half of those previously
recorded in our country for patients undergoing the same surgery with
an open approach.39

Early outcomes of this study confirm similar results reported in the literature for single center studies.14–16,22,40
It’s important to underline that to safely perform LVBG and LASGB the
surgical team should have not only a good experience of advanced
laparoscopic surgical techniques, including suturing and stapling, but
also a good experience in open bariatric surgery and in the
perioperative management of bariatric patients.

Based upon midterm and long-term results, LVBG is significantly superior to LASGB. LVBG has lower morbidity (14% vs. 32.7% with P < 0.05), reoperative rate (0% vs. 24.5% with P < 0.001), and more successful weight loss. Nilsell et al,19
in their randomized trial on open adjustable banding and VBG, found
different results, with a lesser weight loss and more reoperations
following VBG, but gastroplasties were performed according to the
original Mason technique,38
with 18.5% of staple line disruptions. These complications were
probably the reason of unsatisfactory results on weight loss and
consequent reoperations; furthermore, the use of silicone collars could
lead to a high percentage of outlet stenosis and reoperations.41

In
our study, late slippage of the gastric restrictive band represents the
most common problem as seen in 9 cases (18%). For specific purpose of
reducing band slippage, the technique of LASGB underwent several
modifications during the time. Specifically, Favretti et al37 and Belachew et al42
proposed placement of the band above the bursa omentalis and suturing
it with four or more gastrogastric knots reducing the slippage rate
from first reports of ≥50%17 to a range of 5% to 21%.14–16,42,43
All bands in this trial were positioned according to this technique.
Some authors suggest a long learning curve is the most likely culprit
for band slippage. O’Brien et al16
report a slippage rate of 12.5% during the first 350 cases and only 1%
in the following 350 cases. All bands in our trial were placed by the
same surgeon (M.M.) with a previous experience of more than 5000
laparoscopic procedures, 300 laparoscopic bariatric procedures, and 40
LASGB; if a longer learning curve is required, very few surgeons will
be able to complete it.

We did not experience erosion of the gastric wall, a complication reported by several authors at a rate of 1% and 3%.16,37

In
the effort to further reduce late complications, new models of the
gastric band have been recently developed, for which there are no
results reported in literature.

In terms of weight loss, LASGB results were not satisfactory at the 1-, 2-, or 3-year intervals (Fig. 1).
Different weight loss outcomes following LASGB are reported in the
literature. Several authors report results similar to this study7,14,15 with a resulting BMI at 3 years of 33 to 36 kg/m2. On the other hand, some series report better outcomes40,44 with a resulting BMI around 30 kg/m2.
The main difference of these studies seems to be the selection of the
patients. Restrictive gastric surgery is more efficient in mildly obese
patients, rather than the superobese patient population. In studies
with the best results,40,44 the preoperative average BMI was 42 to 43 kg/m2. In studies with the poorest results, initial BMI was 44 to 46 kg/m2.7,14,15 Moreover, studies with better results40,44
stress diligent and meticulous follow-up with an intense program of
alimentary education for LASGB patients. Therefore, the data from our
randomized trial provide significant insight. Two groups of patients
with the same preoperative BMI, with the same postoperative follow-up,
demonstrated a greater weight loss in the group that underwent LVBG
than those that underwent LASGB.

This
study demonstrates that in a carefully selected group of European
patients, nonbinge and nonsweet eaters with an initial BMI limited to
40 to 50 kg/m2, restrictive surgery can have good results
using LVBG but not LASGB. We have previously demonstrated that in
patients with a BMI > 50 kg/m2, even LVBG provides disappointing long-term results.24 We suspect a more complex procedure, such as gastric bypass, is required in these patients.

This
study confirms that restrictive procedures, in particular LASGB, are
safe. At the same time, it emphasizes the superiority of LVBG with less
morbidity and better weight loss. It also confirms concerns of some
authors13,45
regarding the uncontrolled spread of the gastric banding without
verification of the long-term outcomes. Its use was supported by
technical feasibility and the benefits of a minimally invasive
approach. Following the release of data summarized in this article, we
have decided to suspend the routine clinical application of the LASGB.
Its use is now limited to selected patients in which the advantages of
a less complex and totally reversible procedure are the factors
determining the choice of the surgical technique (eg, high
anesthesiological risk, and BMI between 35 and 40 kg/m2).

ACKNOWLEDGMENTS

The
authors thank Don Selzer, MD, Department of Surgery, Mount Sinai
Minimally Invasive Surgery Center, New York, NY, for revising the
manuscript and Riccardo Ragona, MD, Department of Radiotherapy,
University of Turin, Italy, for his help with the statistical
evaluation of data.

Discussion

Dr.
H.W. Tilanus: Thank you very much. I enjoyed your paper, but I still
have a couple of questions. The first question is: is there a special
way to put the Veress needle into these very obese patients? And the
second question is: do you need a polypropylene mesh? My last question
regards the long-term results because we have now only the early and 2-
and 3-year results. I think in the long-term one of the major problems
is the development of malabsorption syndrome as described in patients
after gastric bypass.

Dr. M.
Morino: I agree that it is sometimes difficult to perform
pneumoperitoneum in bariatric patients. We use the standard Veress
needle in the large majority of patients, but sometimes we use a visual
trocar to enter the peritoneum. Concerning the mesh, in this study we
have used a polypropylene mesh, the very same mesh that we were using
in open surgery. Different studies concerning open VBG have compared
different materials and shapes for the calibrating mesh, concluding
that a polypropylene mesh 5 × 1.5 cm is the best mesh in terms of
effectiveness and long-term results.

Your
question on long-term results is important; on the very long period,
restrictive procedures have all the same problem: some patients tend to
regain weight. But this study was aimed to compare two restrictive
procedures, so the problem will be, in my opinion, similar in both
groups. Both procedures do not cause malabsorption either in the short
term or later on. Nevertheless, it is our experience that at 5 years
the results of VBG are still good, while some patients gain weight
between 5 and 10 years from surgery. This is why recently there is a
tendency to increase the indications to gastric bypass or malabsorptive
procedures.

Dr. A.G. Johnson: May
I congratulate you on a beautifully designed study and power
calculations before you started; that is excellent.

What
surprised me was that you kept the patients after VBG in so long, ie,
6.5 days. I only keep my open VGBs in that length of time, so it does
not seem that you have taken advantage of the less invasive approach.
Why should there be a big difference between the two groups if they are
both done laparoscopically?

Dr. M.
Morino: I’m aware that a patient in the United Kingdom or United States
is usually dismissed on the second or even the first postoperative day
after laparoscopic bariatric surgery. Nevertheless, our attitude tends
to be more conservative concerning hospital stay: we perform a
water-soluble x-ray control during the second postoperative day in the
LVBG group and on the first postoperative day in the LASGB group, and
the patient leaves the hospital 1 or 2 days later. Therefore, the
difference in hospital stay between the two groups is a consequence of
a 24-hour delay in performing the x-ray control and of a higher rate of
complications in the LVBG group. Furthermore, the mean hospital stay in
the LVBG group is influenced by the only severe complication in both
groups: a fistula necessitating a reoperation on the second
postoperative day and an overall hospital stay approaching 2 months.

Dr.
P.A. Clavien: This is a very nice study comparing the two most widely
used restrictive procedures to treat morbid obese patients. I have two
questions. You included only patients with a BMI between 40 and 50.
While most bariatric surgeons currently perform a restrictive procedure
in this population, they prefer a malabsorptive procedure in those with
a BMI above 50. Would you consider similar studies using a restrictive
procedure in those with a higher BMI? Second, what would be your next
study? Since you have initiated this study in 1999, we have gained wide
experience with laparoscopic gastric Roux-en-Y bypass, including low
complications rates. Would you consider to compare your best
restrictive procedure, ie, vertical gastric banding, with laparoscopic
gastric Roux-en-Y bypass in patients with a BMI between 40 and 50?

Dr.
M. Morino: We follow the indications to bariatric surgery that were
defined at the Consensus Conference of Bethesda, in 1991: a BMI over 40
or between 35 and 40 when the patient has comorbidities. We never
operate on a patient with a BMI between 30 and 35. We are very strict
in indications, and I would like to stress the medicolegal issue in
bariatric surgery. This is a very delicate surgery on the side of
medicolegal issues and surgeons should be extremely cautious with
patient selection. Maybe that in the future, due to the good results of
laparoscopy, the indication will be enlarged, but for the moment we
maintain the same indications as in open surgery.

Dr.
J. Perissat: Mr. Chairman, Dear Colleagues: There is no doubt that the
laparoscopic approach has completely rejuvenated the bariatric surgery.
It deletes all the complications linked to laparotomy, that is, on
obese people, the addition of new sources of morbidity even mortality.

But we have not yet clear ideas about the choice of the various proposed procedures.

Professor
Morino provides us, for the first time as far as I know, a document of
highest level of evidence, able to guide our choice between the two
major so-called “restrictive” procedures. I share completely his
conclusion. But I do not think that we have to give up the use of
gastric banding placement. Professor Morino omits in his presentation
and abstract (I did not have the opportunity to read the entire paper)
to outline that the gastric banding is a quite easy reversible
procedure also by laparoscopic approach. This is not the case for the
Mason one. Easy to replace and retrieve, having immediate excellent
results on weight loss but not so good long-lasting ones, the banding
could be inserted in a new strategy for obesity cure. It could become a
tentative operation enabled to have a quick weight loss relayed in case
of obesity beginning of recurrence by more long-term successful
procedures, such as gastric bypass or other so-called “nutritional
effect” operations.

I would like to know the opinion of Professor Morino on that.

Mr.
Chairman, let me thank you to give me the privilege to comment on this
presentation. I appreciate it very much. It comes from one of our main
new leaders in Laparoscopic Surgery.

Dr. M. Morino: Thank you Professor Perissat for your comments.

First
about reversibility: the Mason technique is reversible. You can staple
together with a linear stapler the two pouches leaving in place the
prolene mesh. By doing so, you will lose every restrictive effect and
the patient will eat normally. The band is easier to remove, but we do
not choose a procedure because it is easy to take down. The problem
with bariatric surgery is that if you do a reverse procedure, the
patient will go back to his or her eating habits and will progressively
gain weight.

Concerning
your comment on the use of the band as a tentative operation to verify
if the patient will lose weight with a restrictive procedure, we prefer
to use the endoscopic intragastric balloon in this setting. When we are
not sure that the patient will have a good result with the restrictive
procedure, we use flexible endoscopy to put in place an intragastric
balloon. The patient will have the balloon for 4 to 6 months: if he or
she loses weight with the balloon, we will go on with another
restrictive procedure that is LVBG: on the contrary, if the balloon is
not effective, we will propose to the patient a laparoscopic gastric
bypass.

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and consultation form your own local physician. Read more here...

-This site is intended as a resource
for references on the treatment of obesity for health care
professionals and educated consumers. Read more here...

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information that is complete and generally in accord with the
standards accepted at the time of publication. Read more here...

-Medical knowledge changes rapidly. In
view of the possibility of human error or changes in medical science,
neither the authors nor the editors nor any other party who has been
involved in the preparation or publication of this work warrants that
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complete, and they are not responsible for any errors or omissions or
for the results obtained from the use of such information. Read more
here...

-This information is not medical advice
or diagnosis, nor is it to be construed as medical advice, medical
information, medical diagnosis, or medical prescription for curing,
removing, or preventing any disease, or related symptoms. Read more
here...

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any information found herein. Read more here...

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Warning: Gastric Bypass Surgery is a
MAJOR surgical procedure. It can be associated with significant risks
and complications, up to and including death. Weight loss surgery is
a rapidly developing area of medicine. Bariatric surgery is filled
with controversy. It is very important to take a careful and
deliberate approach to considering surgery for the treatment of
obesity.

Disclaimer Notice:-Information on this
web site is provided for informational purposes only.-It is
imperative that you consult your own physician regarding the
applicability of any opinions or recommendations with respect to your
symptoms or medical condition.

-Contact with this web site or Dr.
Rutledge over the web site does not constitute a doctor patient
relationship and for good quality medical care you must obtain advice
and consultation form your own local physician.

-This site is intended as a resource
for references on the treatment of obesity for health care
professionals and educated consumers.

-The authors and editors have used
sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the
standards accepted at the time of publication.

-Medical knowledge changes rapidly. In
view of the possibility of human error or changes in medical science,
neither the authors nor the editors nor any other party who has been
involved in the preparation or publication of this work warrants that
the information contained herein is in every respect accurate or
complete, and they are not responsible for any errors or omissions or
for the results obtained from the use of such information.

This information is not medical advice
or diagnosis, nor is it to be construed as medical advice, medical
information, medical diagnosis, or medical prescription for curing,
removing, or preventing any disease, or related symptoms.

You must seek the direct assistance,
advice and evaluation of your own personal physician before acting on
any information found herein.

These statements have not been
evaluated by the Food and Drug Administration.-Readers are Strongly
encouraged to discuss and confirm the information contained herein
with your own physician.